Provider Demographics
NPI:1902834070
Name:TARR, KENNETH P (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:P
Last Name:TARR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:562-499-6171
Practice Address - Street 1:4700 SCHAEFER RD.
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3698
Practice Address - Country:US
Practice Address - Phone:313-581-2600
Practice Address - Fax:313-581-0228
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010086882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICA5318OtherMEDICARE RR GROUP PIN
MI1876132Medicaid
MI300073227OtherRRMC
MI3156310454OtherBCBS PIN #
MI1876123Medicaid
MI310D460020OtherBCBS GROUP PIN
E26266Medicare UPIN
MI1876123Medicaid
MI310D460020OtherBCBS GROUP PIN